Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.orgwww.entnet.org
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care
Solving Carrier IssuesAMERICAN ACADEMY OF OTOLARYNGOLOGY –HEAD AND NECK SURGERY and FOUNDATION (AAO-HNS/F)
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.orgwww.entnet.org
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care
SOLVING CARRIER ISSUES:
FIRST STEPS
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Solving Carrier Issues: First steps
▪Basic first steps
▪Are you following CPT Guidelines and using
modifiers correctly?
▪ CPT® coding book
▪ Specialty coding resources
▪ CPT® Assistant
▪ NCCI (national correct coding initiative edit pairs)
▪Have you and/or your staff cultivated a good
relationship with your carrier representative?
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
▪Have you reviewed your contract and payment
policies (usually online)?
▪ Are YOU following them?
▪ Are THEY following them?
▪Have you filed an appeal and escalated up the
chain as necessary, including asking for rationale
for denial?
▪Have you contacted the medical director in writing
with documentation/support for your position and
asked for a phone/face-to-face conversation?
Solving Carrier Issues: First steps
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
▪Did you contact your county and state medical
society?
▪ Existing relationships with carrier leadership
▪ Coding/appeal advocates
▪ Determine the scope of the issue. Other specialties
affected?
▪Does your ENT society/specialty society have
coding/payment resources/experts (e.g. NYSSO)?
▪ENTConnect outreach to peers
▪Academy resources
Solving Carrier Issues: First steps
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.orgwww.entnet.org
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care
SOLVING CARRIER ISSUES:
STEP-BY-STEP APPROACH
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
So… How is it
Done???
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Local / State Advocacy Tips
▪ Verify initial denial and collect information needed subsequently. ▪ Check your own internal procedures.
▪ Develop a relationship with the Medical Director.▪ State society can help with this.
▪ Ask for more information about the rationale used for the denial.
▪ Explain your practice patterns.
▪ Try to reach reasonable and appropriate consensus.
▪ Keep your BOG Regional Representative apprised of the
issue/outcome. ▪ Try to solve local issues locally.
▪ http://www.entnet.org/content/bog-region-map
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Insurance Coverage Challenges
▪ Avoid a denial in the first place ▪ Proper coding
▪ AAO-HNS Resources
▪ AMA Resources (CPT® Assistant, RUC Database®)
▪ Others (CodeManager®, EncoderPro®)
▪ NCCI Edits (www.cms.gov)
▪ Proper use of modifiers (NCCI edits)
▪ Proper documentation
▪ Check your own office procedures/training
▪ Many denials come from the incorrect ICD code being
used or incomplete information being sent (doc-to-doc
appeal calls can help!)
▪ Be familiar with carrier idiosyncrasies ▪ Pre-certification
▪ Pre-determination
▪ Do they use NCCI edits?
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
How is it actually done?
1. Get the right contact information.a. State Medical Society and State Oto/BOG Society
2. Initial phone call with Medical Director.a. Just listen (get to know their side - policies are not pulled out of a hat)b. Follow up with email/letter
3. Gather your data.a. Specific patient denialsb. Local opinion/practice patternsc. Literature
4. Follow-up phone call with Medical Director.a. Discuss specificsb. Group call/webinar with a committee from your state societyc. Written letter (summarize “3” above) - possibly before and after call
5. Written letter/correspondence of final request/agreements.
6. Keep State Society/BOG Regional Rep in the loop.
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example (all PHI changed)
35y/o patient with 6 months of recurrent bilateral facial pressure, pain,
nasal congestion, and thick rhinorrhea.
•Three “exacerbations” in the past 6 months.
•Each treated with either Amoxicillin for 10 days or a Z-pak, and Medrol
Dosepak from PCP.
•Given 21 days of amox/claf and 7 day prednisone course by otolaryngologist
and started on sinus rinse and Flonase.
•Allergy testing positive only for HDM and dander.
•CT scan (performed after first 4 weeks of therapy) showed: mild mucosal
thickening left maxilary sinus, minimal mucosal thickening left frontal sinus, left
anterior ethmoid with low grade changes of chronic sinusitis, bilateral concha
bullosa, and bilateral inferior turbinate hypertrophy.
•Options discussed with patient and criteria reviewed.
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Reviewed carrier’s criteria for sinus ostial dilation (prior auth not required at
time of service and no criteria for other procedures):
Patient Selection Criteria for Chronic Rhinosinusitis
Coverage eligibility will be met when the following criteria are present:
• Chronic rhinosinusitis in an adult which has persisted for a minimum of 12
weeks despite failure of aggressive medical therapy. This should include
documentation of treatment with all of the following:
o Saline nasal irrigations or saline nasal spray
o Intranasal corticosteroids for at least 8 weeks
o Two courses of antibiotics or one prolonged course of oral antibiotic for at
least 21 days
• Chronic rhinosinusitis of the sinus to be dilated is confirmed on computed
tomography as evidenced by significant mucosal thickening of greater than 3
mm, opacification, or air-fluid levels documented by a formal CT scan report
from an independent radiologist.
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Reviewed carrier’s criteria for sinus ostial dilation (prior auth not required at
time of service and no criteria for other procedures):
Patient Selection Criteria for Recurrent Acute Rhinosinusitis
Coverage eligibility will be met when the following criteria are present:
• Four or more documented and treated episodes in a 12 month period; and
• CT imaging performed during the fourth episode should demonstrate pathology
in the sinus to be dilated that meets the same CT imaging criteria (significant
mucosal thickening of greater than 3 mm, opacification, or air-fluid levels
documented by a formal CT scan report from an independent radiologist)
Radiologist Addendum obtained for CT scan:
•Left maxillary sinus thickening of 6mm
•Left frontal sinus thickening of 3mm
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Performed:
• Left maxillary sinus ostial dilation
• Left frontal sinus ostial dilation
• Left anterior ethmoidectomy
• Bilateral submucous inferior turbinate resection
• Bilateral concha bullosa resection
Result:
• Entire service denied
• Denial upheld on appeal
• Letter written to Medical Director
• All but frontal sinus dilation paid upon receipt of letter
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Suboptimal appeal letter (what we want to write):
•“I asked for an addendum to the radiologist reading to address the
thickness in mm of the mucosal inflammation in the sinuses. I had to do
this because of the carrier recommendations on findings of chronic
sinusitis that qualify for in office balloon dilation.”
•“I offered in office balloon dilation of the maxillary sinus as well as the
resection of the concha bullossa / anterior ethmoidectomy and
submucosal resection of her inferior turbinates. I felt the patient would
benefit from a frontal balloon sinus dilation on the left as well due to the
high agger nassi cell and ( 3mm ) of mucosal thickening, even though
the carrier guidelines do not think a patient with this scenario would
benefit. I planned to do it for free because the patient would
benefit, and at least I was going to get coverage of the maxillary balloon
to cover my expenses of the equipment. I was wrong on all counts.”
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Suboptimal appeal letter (what we want to write):
•“So now at this point if you look at my post op encounters with this
patient, he/she is very happy and pleased with the outcome. The carrier
is very pleased with their outcomes because they have a happy client
who got treated for free. I am not so happy because I am out the cost of
the balloon system, my personal time, office time, employee time,
malpractice risk and more. I am not happy because I did my part and
followed these carrier imposed guidelines and still got denied initially
and on appeal. Can someone please explain to me how this
happens? Why do I have to expend this much energy, time, and money
just to get paid?”
Don’t Press Send!!!
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Successful appeal letter (no emotion):
•“Therefore, in order to determine if this patient met the criteria specified
by carrier for sinus ostial dilation, I asked the radiologist for an
addendum to his reading to address the thickness in mm of the mucosal
inflammation in the sinuses, and this document is attached. Please see
the addendum at the end of the report specifying 6mm of mucosal
thickening in the left maxillary sinus.”
•“Given that the left maxillary sinus had mucosal thickening of greater
than 4mm, and that the patient had over 12 weeks of symptoms after
aggressive medical therapy, and 4 episodes of acute sinusitis treated
with antibiotics in the preceding 12 months, I was certain that the patient
satisfied the criteria of his/her carrier for an in-office sinus ostial
dilation. Given that her/his preference was for the in-office procedure,
we scheduled the procedure.”
(No complaint)
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Successful appeal letter (no emotion):
•“I also want to note that I am not appealing the denial of the frontal
dilation. Although the thickening did not meet the carrier threshold of
>3mm, I felt that the patient was having recurrent and chronic symptoms
from this sinus and elected to treat it. My appeal is specifically for the
denial of the left maxillary sinus dilation, as the patient clearly meets
criteria for this sinus.
•Secondarily, I would like to know why the other services—the turbinate
reduction, concha bullosa resection—are also being denied. This does
not make any sense. (Direct and firm)
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Successful appeal letter (no emotion):
•“Finally, at this point if you look at my post op encounters with this
patient (attached), she/he is very happy and pleased with the
outcome. I have been able to spare the patient the morbidity of a
procedure under general anesthesia, and thought that I was saving the
carrier money by sparing them a costly facility fee. I also thought that I
had met the carrier’s criteria for sinus ostial dilation. However, I find
myself frustrated and angry because I did my part to verify that the
patient met your criteria but am still out the cost of the balloon system,
my personal time, office time, employee time, and malpractice risk. This
is simply not just. Therefore, I am asking for the following:”
Make a Specific Demand
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Successful appeal letter (no emotion):
1. I need someone to please explain to me exactly which criteria I did not meet,
because I reviewed your criteria (attached), and I feel like I did meet them.
2. Please remit payment for the turbinate reduction (30140-50), partial
ethmoidectomy (31254), and concha bullosa resection (31240-50) as soon as
possible. These are not subject to prior authorization, and their payment should
not be delayed while we further appeal the dilation denial.
3. If, upon further review, you find that I did meet criteria for ostial dilation,
please remit payment as soon as possible.
4. If, upon further review, you find that I did meet criteria for ostial dilation,
please provide a detailed explanation of how the initial and appeal denials
happened. Was inadequate documentation provided? Did the reviewer not see
something that was in the documentation? Was the radiologist addendum
seen? (Try to find out what happened)
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Real Life Example
Successful appeal letter (no emotion):
•“Thank you for your time and consideration in this matter. As you can
imagine, I am finding myself confused, frustrated, and angry that so
much extra time and energy has to be expended simply to be paid for
medically justified and necessary work. I look forward to your reply and
resolution of this problem.”
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Appeal Letter – Key Points
1.Leave emotion at the door.
2.Be respectful.
3.Do not complain.
4.Stick directly to the facts.
5.Reference specifically the carrier’s criteria and how your patient satisfied it.
6.Be direct and explicit in what you are asking them to do.
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Academy Resources
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Academy Resources
http://www.entnet.org/content/practice-management
COMING SOON – ALL HEALTH POLICY RESOURCES WILL BE ACCESSIBLE IN
ONE CENTRAL LOCATION – WWW.ENTNET.ORG/ADVOCACY!
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Health Policy Academy Resources
▪ Clinical Practice Guidelines and Clinical
Consensus Statements
▪ Clinical Indicators and Position Statements
▪ Coding corner/CPT for ENT and CPT Assistant
as needed
▪ Template Appeal Letters and Advocacy
Statements
▪ Private Payer Advocacy Updates
Empowering otolaryngologist–head and neck surgeons to deliver the best patient care www.entnet.org
Health Policy Academy Resources
▪ CMS and Federal Advocacy
▪ Research and Quality Improvement
▪ Inquiries
a. MIPS
b. Medicare Fee Schedule
c. NCCI Edits (CPT Team)
a. Patient Safety Event Reporting Tool:
www.entnet.org/content/patient-safety-tool
a. Practice Management Member Inquiry Form:
www.entnet.org/content/practice-management-tool
b. Monitor local issues to identify national trends